CRISIS BEST PRACTICES WORKGROUP September 15 2017 Todays

CRISIS BEST PRACTICES WORKGROUP September 15, 2017

Today’s Agenda • Welcome • Program Spotlight: Hope Network (Grand Rapids, MI) • Content Overview: Clinical Services & Training • Review Survey Results/Discussion • Review Project Plan and Timeline • Adjourn Purpose: To develop a comprehensive Best Practice Toolkit for Crisis Residential Services, informed by Crisis Residential providers across the country.

Crisis Best Practices Workgroup TBD Solutions is proud to sponsor the Crisis Best Practices Workgroup. ü Crisis Program Development ü Quality & Process Improvement ü Metrics Development ü Integrated Care Coordination ü Middle Management Training ü Research & Analysis ü Interactive Data Visualization ü Software Procurement Consulting www. TBDSolutions. com

Crisis Services Map

Workgroup Participants • 141 participants • 98 Crisis Residential Providers • 10 Crisis Providers, Psych Hospitals, or Peer Respites • 4 State Behavioral Health Administrations Represented (TX, VA, WI) • 44 states • Plus D. C. , England Costa Rica • Approximately 390 crisis homes exist nationwide • Welcome new participants from DC, WV, NJ

BEHAVIORAL HEALTH SERVICES Crisis Residential Programs

Pivot Crisis Robert Brown Crisis • Grand Rapids, MI • Holland, MI • 16 beds • Urban/Residential Area • Quiet, residential street • 15 Contracts (14 CMH, 1 health plan)

Philosophy & Values • Person-Centered • Welcoming • Structured but home-like environment • Start with “How can we adjust to better serve this person? ” • Skills focused group and individual sessions daily • Peer Support • Community Collaboration

Community Collaboration Bringing Services In Communicating Out • Pet Therapy • “Dog & Pony Show” • Art Therapy • Internal education • Faith Services • Emergency Departments • AA/NA • • Street. REACH Sharing outcome data with funders and potential funders • Engaging staff in community events (fund raising, issue awareness) • Red Project • Safe Haven

Next Steps • Expand payer contracts • Enhance SUD service capacity and competency • Advocate at state and national level for increased use of alternatives to hospitalization • Partner with inpatient and outpatient providers to improve care transitions • Enhance Follow-Up program

Content Review: Clinical Services & Training December 2016: Staffing May: Intake January 2017: Scope & Function June: Funding February: Metrics & Outcomes July: The Safety Net March: Taxonomy & Community Relations August: Regulations & Governance April: Treatment Philosophy & Approach September: Clinical Services & Training

Clinical Services & Training • Unraveling the Mystery of Crisis Intervention Services • Education and Training • Services Provided • Evidence Based Practices…and Accompanying Challenges • Managing Risk vs. Improving Quality of Life • Supporting Staff in Times of Extreme Need • Helpful & Effective Resources

Education & Training Recreational/Activity/Music Therapist N/A- We do not have these staff in our Crisis Program(s) Prescribing Doctor (Psychiatrist, Nurse Practitioner, Physician's Assistant) Ongoing Training on Specific Populations (Refugees, Individuals who are Transgender, etc. ) Trauma-Informed Care Training (ex: Seeking Safety) Nurses (RN/LPN) Clinicians (Therapist, Social Worker, or Case Manager) Certifications (Peer Support, Psychiatric Rehab Practitioner, Mental Health First Aid, etc. ) Basic Health Care Professional Training (Crisis Intervention, Recipient Rights, CPR/First Aid, etc. ) Peer Support Specialists Relevant Education (Bachelors/Masters/Ph. D/MD, etc. ) Direct Service Professionals 0% n=25 20% 40% 60% 80% 100%

Services within Scope of Practice Recreational/Activity/Music Therapist Psychosocial Assessment Prescribing Provider (Psychiatrist, Nurse Practitioner, Physician's Assistant) Health Assessment Prescribing Medications Nurses (RN/LPN) Individual/ 1 -on-1 Support Clinicians Individual Therapy/Group Therapy De-Escalation/Crisis Intervention Peer Support Specialists Medication Administration Direct Service Professionals 0% n=25 20% 40% 60% 80% 100% Psychoeducational Group Faciltiation

Evidence Based Practices Which Evidence Based Practices does your Crisis Program offer? 100% Cognitive Behavioral Therapy (CBT) Wellness Recovery Action Planning (WRAP) Dialectical Behavior Therapy (DBT) Other EBPs 90% 80% 70% 60% 50% 72% 60% 52% 40% 30% 20% 10% 0% n=25 28% 24% 12% Acceptance and Commitment Therapy (ACT) N/A- We do not offer Evidence Based Practices

Evidence Based Practices n=25 • Motivational Interviewing • Trauma-Focused Cognitive Behavioral Therapy (TFCBT) • Seeking Safety • Living Room Model • Solution Focused Therapy • Integrated Dual Disorder Treatment (IDDT) • Illness Management and Recovery (IMR)

Challenges to Maintaining Fidelity to EBPs What are the biggest challenges to maintaining fidelity to Evidence Based clinical models? 100% 90% 80% 70% 65% 50% 52% 40% 43% 30% 20% 30% 13% 0% Client Length of Stay n=25 Staffing Resources High Turnover Program Structure Cost of Clinical Training N/A- we don't offer Evidence Based Practices “Treatment clinicians are also responsible for managing all admissions, so more admissions means less time for group or 1: 1 interventions. Plus the average length of stay is only 3 -5 days. ”

Further Exploration in EBP Fidelity • Exploring partnerships with local universities and researchers • Grant-Funded Research (ex: NIMH) • Collaboratively creating materials with other crisis providers

EBP Accommodations How have you adapted concepts of Evidence Based Practices to adjust to program structure limitations or meet the unique needs of the individuals you serve? “We introduce skills training groups, skills training manual handouts, we use the language and interventions in individual, group, and milieu interactions as well as our documentation. ” “Shorter and more intense forms of these treatments. ” “Pick and choose Seeking Safety concepts as needed in milieu as opposed to going in order of concepts. ” “Most of our clients are in the Precontemplation or Contemplation stages of change and research shows individuals are not responsive to therapy and even skills training until they reach the Action stage - so the focus is on psychoeducation/building awareness. ” n=25

Crisis Services: The Magic Sauce What are Crisis Stabilization Services about? Managing risk? Not dying? or Improving function? Living?

Clinical Services: Maintaining Safety and Mitigating Risk How does your program maintain safety and mitigate risk for persons served? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Safety policies n=25 Medication Storage House Rules Safety Protocols (Eyes-on, Arms length, etc. ) Safety Plan Development Daily Risk Regular checks Assessments (if (i. e. 15 -minute applicable) intervals) Elopement Procedures Physical Restraint

Clinical Services: Maintaining Safety and Mitigating Risk • Secure entry • Locked personal and hygiene items • “We have no rules-just expectations that client will work on resolving their crisis and expectations that talk about respect for self and others. ” • Being able to decline admissions based on acuity, violence or medical complexity • Panic buttons • Admission/Participation Agreement signed by client

Clinical Services: Promoting Recovery and Wellness How does your program promote recovery, hope, symptom reduction, and social connectedness? Community-Integrated Groups Medication Passing Recreational Groups Physical Health & Wellness Referrals Individual, Group, or Family Therapy Medication Reviews Daily Goals Medication Education Therapeutic Groups Daily 1: 1 contact/interaction Linkage/Referral to Community Resources 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Clinical Services: Helpful & Effective Resources Which of these resources have you found to be helpful in meaningfully addressing symptoms, facilitating psycho-educational groups, or helping clients achieve recovery goals? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CBT Worksheets n=25 DBT Worksheets WRAP Worksheets Original/Customized Symptom Rating ACT Worksheets Scales (PHQ-9, GAD -7, etc. ) Other Choices in Recovery (Janssen)

Clinical Services: Supporting Staff in Times of Need How does your program support staff in times of significant need? 100% 96% 92% 80% 88% 70% 68% 60% 50% 40% 32% 20% 10% 0% Regular Debriefing Processing in staff meetings following stressful/traumatic events Regular supervision FMLA/Extended Leave Paid Time Off for Mental Health Days Other

Clinical Services: Supporting Staff in Times of Need • “As a company we have an internal response team designed to respond to any event that may require supporting staff. ” • Employee Assistance Programs (EAP) • Peers provide support • Daily huddles • Staff workout room • Quiet room for staff only • Free yoga classes on-site • Self-care days with massage

Clinical Services: Maintaining a Thriving & Effective Crisis Program “Staff recognition and staff support” “We regularly meet with stakeholders and hold consumer advisory meetings to improve program development. ” “We encourage all staff to bring innovative group [therapy/psychoeducation group] proposals to the table. ” “We have weekly leadership meetings with the supervisory staff assigned to those areas, to problem solve, exchange ideas, and promote good care of our clients and staff. ” n=25 “We have found on our discharge surveys that many individuals found the one-on-ones with Crisis Counselors [to be] the most helpful. We plan to continue this process. ”

Survey Participation Completed Surveys 100 90 80 70 60 50 42 40 36 35 34 30 20 31 30 20 16 23 25 August September 10 0 December January February March April May June July

Survey Participation & Incentives Average participation is 29% of Crisis Residential Providers Completed Surveys 100 90 70 60 50 42 36 40 35 34 30 31 30 25 23 20 16 20 10 Se pt em be r st gu Au ly Ju ne Ju ay M ril Ap ch ar M ry ua br Fe nu ar Ja m be r y 0 ce Participants who contribute through substantial survey completion will also be recognized as contributors in the Toolkit 80 De Crisis Residential Providers who complete 80% of surveys or more will have early access to Best Practices Toolkit

Survey Participation & Incentives • Missing surveys will be sent to you by 9/30/17 • Please complete missing surveys within 30 days of receiving request • Email Claudia at claudiav@tbdsolutions. com with any questions

Crisis Services Database • Surveying for all Crisis Services in each State • Crisis Residential • 23 Hour Crisis Stabilization • Mobile Crisis • Psychiatric Hospitals • State Psychiatric Hospitals • CIT Teams • Peer Respites • Email claudiav@tbdsolutions. com

SAMHSA Webinar Series(es) 4 th Monday of each month April-September 1 -2: 30 pm ET/11 am-12: 30 pm PT https: //tinyurl. com/y 9 wpvu 6 a 3 -4 pm ET/12 -1 pm PT https: //tinyurl. com/mezytde

Next Steps Next Conference Calls: Wednesday, October 25 th @ 2 pm EDT/11 am PDT Group Listserv: Crisis. Residential. Network@TBDSolutions. com Website: www. Crisis. Residential. Network. com (Meeting Slides stored here) Questions: Travis. A@TBDSolutions. com